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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED (".'R'ONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is In full force and effect, <br /> License#: 4-ys- Exp Date: <br /> Date: <br /> Contractor: <br /> Signature: 4214 Title: <br /> Print Name: <br /> gng�-�-&&� <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the perfo.-mance of the work for which this permit is issued. My workers' <br /> compensation insurance o*rrier and policy number's are: <br /> Carrier;Sl e�ajjza Policy Number: Z,9,9 6)9 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should becc rie subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I Shall forthwith comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRINNAL PENALTIES AND CIVIL.FINES UP TO$100,900,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AqTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-67 licensed authorized representative), <br /> hereby au"f6orize(print name) --E—U-6eii L-,--de-tm-o, ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application, <br /> 8129102MI <br /> EHO2941 11M7 WELL PERMrr APP <br />